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| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
| Image = Sinus arrest.gif| | | Image = Sinus arrest.gif| |
| Caption = | | | Caption = | |
| DiseasesDB = |
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| ICD10 = {{ICD10|I|45|5|i|30}} |
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| ICD9 = {{ICD9|426.6}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D012848 |
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| }} | | }} |
| {{SI}} | | {{Sinoatrial arrest}} |
| {{WikiDoc Cardiology Network Infobox}}
| | '''For patient information, click [[Sinoatrial arrest (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}} |
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| {{Editor Help}} | | {{SK}} sinus arrest; sinus pause |
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| ==Overview==
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| Under certain circumstances, the [[SA node]] fails to initiate an impulse at the expected time in the [[cardiac cycle]]. In the absence of an impulse from the SA Node neither the atria nor the [[ventricle]]s are stimulated and thus an entire PQRST complex drops out for 1 beat(or more). This is called Sinoatrial(SA) Arrest. In other instances the impulse is initiated normally but is blocked within the SA Node and never reaches the atria and ventricles. This is called sinus exit block or sinoatrial block. Sinus arrest is one of several variants of [[sinus node dysfunction]]. The word sinus pause is used to indicate a pause in the generation of QRS complexes for 3 seconds or less. If the delay is longer than this, then the term sinus arrest is used. If there is a markedly prolonged or permanent cessation of [[P wave]] and [[QRS]] complexes, then the term a[[systole]] is applied.
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| ==Epidemiology==
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| Sinus arrest is fairly uncommon. It is more likely to be observed in elderly patients with a senescent rhythm system. It can be observed in the setting of myocardial disease ([[myocarditis]]) and ischemia or infarction (particularly acute inferior or posterior [[ST segment elevation MI]]). It can be a manifestation of [[digitalis]] or [[lidocaine]] toxicity.
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| ==Pathophysiology==
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| If there is absence of a [[P wave]] or a dropped [[P wave]], it is difficult to determine from the surface EKG if this is 1) a loss of sinus node automaticity (sinus arrest) or 2) if this is a block of sinus node conduction (sinus exit block). This being said, there are some clinical observations that help distinguish sinus arrest from sinus exit block. In sinus arrest, there is a suppression of other potential escape pacemakers in the atrium so that an atrial escape rhythm is rare. In patients with complete sinus exit block, the block is more frequently associated with either an atrial or an AV junctional escape rhythm.
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| ===Sinus arrest==== | | ==[[Sinoatrial arrest overview|Overview]]== |
| There is no longer generation of pacemaker activity from the sinoatrial node. There is a failure of automaticity in the sinoatrial mode.
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| ===Sinoatrial block=== | | ==[[Sinoatrial arrest historical perspective|Historical Perspective]]== |
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| In this disorder, the sinoatrial node is generating electrical complexes, but the electrical activity fails to conduct in the atrium. Sinoatrial automaticity is preserved, and the p waves are generated at a regular rate in a regular pattern which are a multiple of the basic sinus cycle.
| | ==[[Sinoatrial arrest pathophysiology|Pathophysiology]]== |
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| ====Type I (Wenckebach phenomenon) sinoatrial exit block==== | | ==[[Sinoatrial arrest causes|Causes]]== |
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| The PP cycle is progressively shortened until there is a pause and the cycle is repeated. The pause is due to the dropped P wave and measures less than twice the PP cycle. It is similar to the behavior of the RR intervals in type I second-degree AV block.
| | ==[[Sinoatrial arrest differential diagnosis|Differentiating Sinoatrial arrest from other Diseases]]== |
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| ====Type II second-degree sinoatrial exit block==== | | ==[[Sinoatrial arrest epidemiology and demographics|Epidemiology and Demographics]]== |
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| There is an unexpected drop of the P wave. Following this drop, there is a pause in the sinus cycle which is a multiple of the basic sinus cycle. Blocked atrial premature beats sometimes mimic second-degree sinoatrial block. Third-degree sinoatrial exit block cannot be distinguished from sinus arrest when the sinus node ceases to fire. Under such circumstances, subsidiary pacemakers in the AV junction or ventricles may take over.
| | ==[[Sinoatrial arrest risk factors|Risk Factors]]== |
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| ==Symptoms== | | ==[[Sinoatrial arrest natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| If the AV junctional or ectopic ventricular pacemaker is not sufficiently rapid to generate an adequate cardiac output, then end organ hypoperfusion may result with some of the following symptoms:
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| *[[Angina]]
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| *[[Anxiety]]
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| *[[Confusion]]
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| *[[Congestive heart failure]]
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| *[[Dizziness]]
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| *[[Fainting]]
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| *[[Fatigue]]
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| *[[Lightheadedness]]
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| *[[Palpitations]]
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| *[[Syncope]]
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| ==Differential diagnosis of underlying causes of sinus arrest==
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| *[[Digitalis]] including digitalis toxicity
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| *[[Hyperkalemia]]
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| :* Decreased [[P wave]] amplitude occurs when the K is > 7.0 meq/li
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| :* [[P wave]]s may be absent when the K is > 8.8 meq/li
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| :* The impulses are still being generated in the [[SA node]] and are conducted to the ventricles through specialized atrial fibers without depolarizing the atrial muscle
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| :* Moderate or sever hyperkalemia can cause [[sinus arrest]] <ref name="pmid16792034">{{cite journal |author=Bonvini RF, Hendiri T, Anwar A |title=Sinus arrest and moderate hyperkalemia |journal=[[Annales De Cardiologie Et D'angéiologie]] |volume=55 |issue=3 |pages=161–3 |year=2006 |month=June |pmid=16792034 |doi= |url= |issn=}}</ref>
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| *[[Lidocaine]]
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| *[[Myocarditis]]
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| *Percutaneous coronary intervention of the proximal right coronary artery can obstruct the origin of the SA nodal artery in about 17% of patients (14 of 80 in one series). <ref>Munenori Kotoku, Akira Tamura, Shigeru Naono and Junichi Kadota.Sinus arrest caused by occlusion of the sinus node artery during percutaneous coronary intervention for lesions of the proximal right coronary artery. Heart and vessels,2007, p.389-392</ref> Sinus arrest with junctional escape rhythm went on to develop in 4 of the 14 patients and one patient required a temporary ventricular pacing. There was resolution of the the junctional escape rhythm in all patients within 3 days of the sinus node artery occlusion.
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| *[[ST elevation myocardial infarction]] particularly inferior myocardial infarctions and posterior infarctions.
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| *[[Vagal reaction|Vagal tone]]
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| ==Diagnosis== | | ==Diagnosis== |
| ===Laboratory studies===
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| Serum K+, Ca+ and Na+ should be checked as should [[thyroid function tests]] to rule out [[hypothyroidism]].
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| | [[Sinoatrial arrest history and symptoms|History and Symptoms ]] | [[ Sinoatrial arrest physical examination|Physical Examination]] | [[Sinoatrial arrest laboratory findings|Laboratory Findings]] | [[Sinoatrial arrest electrocardiogram|Electrocardiogram]] | [[Sinoatrial arrest chest x ray|Chest X Ray]] | [[Sinoatrial arrest echocardiography|Echocardiography]] | [[Sinoatrial arrest other imaging findings|Other Imaging Findings]] | [[Sinoatrial arrest other diagnostic studies|Other Diagnostic Studies]] |
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| ==Treatment== | | ==Treatment== |
| ===Acute===
| | [[Sinoatrial arrest medical therapy|Medical Therapy]] | [[Sinoatrial arrest surgery |Surgery]] | [[Sinoatrial arrest primary prevention|Primary Prevention]] | [[Sinoatrial arrest secondary prevention|Secondary Prevention]] | [[Sinoatrial arrest cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Sinoatrial arrest future or investigational therapies|Future or Investigational Therapies]] |
| * Discontinue the agent that may be causing sinus arrest and treat [[hyperkalemia]].
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| * Isoproterenol can be used to increase the rate of the escape pacemaker.
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| * Atropine can be given if the block may be due to heightened vagal tone
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| * Finally, a temporary pacemaker wire can be placed if the patient is symptomatic with end organ hypoperfusion as a result of the AV nodal or ventricular escape rhythm.
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| ===Chronic===
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| *If sinus arrest is part of a chronic condition of [[sinus node dysfunction]] such as the [[tachycardia-bradycardia syndrome]] and if the patient is symptomatic, then permanent pacemaker placement may be neccessary.
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| ==References== | | ==Case Studies== |
| {{reflist|2}}
| | [[Sinoatrial arrest case study one|Case #1]] |
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| {{Electrocardiography}} | | {{Electrocardiography}} |
| {{SIB}}
| | [[Category:Electrophysiology]] |
| | | [[Category:Disease]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
